Little Rock Advertising & Promotion Commission Lodging & Prepared Food Gross Receipts Tax ( A&P Tax ) Application for A&P Tax Permit - Traditional

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1 Appendix Item 8

2 Little Rock Advertising & Promotion Commission Lodging & Prepared Food Gross Receipts Tax ( A&P Tax ) Application for A&P Tax Permit - Traditional 1. Applicant Information Full legal name of applicant for with an A&P Tax Permit is sought (As Doing business as to the public) Physical street address (No P.O. Box) Phone Fax Website Contact person Contact person title Contact person phone Contact person mobile phone Contact person 2. Nature of applicant Sole Proprietorship Corporation (Inc.) Limited Liability Company (LLC) General Partnership (G.P.) Limited Partnership (LTD.) Limited Liability Partnership (LLP) Other (please detail nature of business) Business billing address Phone Fax Business billing contact Title 3. Sole Proprietorship Information (complete only if applicable) Proprietor s full legal name Proprietor s social security number Proprietor s employer ID number (EIN) Proprietor s date of birth Proprietor s place of birth Proprietor s home address County Proprietor s home phone Proprietor s fax Proprietor s mobile phone Proprietor s

3 4. Entity Information (INC., LLC, G.P., LTD, LLP, Other) (complete only if applicable) Headquarters address State of incorporation, formation, or organization Year of incorporation, formation, or organization Headquarters phone Employer ID number (EIN) Name and title of each officer of entity Headquarters fax Shareholder/member/general partner information: Identify below all shareholders, members, or general partners having a 10% or greater equity ownership interest in the applying entity. Full legal name of shareholder/member/general partner Shareholder Member General Partner Natural person Corporation (INC.) Limited Liability Company (LLC) General Partnership (G.P.) Limited Partnership (LTD.) Limited Liability Partnership (LLP) Other (please detail nature of business) Date of birth (only if natural person) Employer ID number (EIN) Phone Fax Full legal name of shareholder/member/general partner Shareholder Member General Partner Natural person Corporation (INC.) Limited Liability Company (LLC) General Partnership (G.P.) Limited Partnership (LTD.) Limited Liability Partnership (LLP) Other (please detail nature of business) Date of birth (only if natural person) Employer ID number (EIN) Phone Fax

4 Full legal name of shareholder/member/general partner Shareholder Member General Partner Natural person Corporation (INC.) Limited Liability Company (LLC) General Partnership (G.P.) Limited Partnership (LTD.) Limited Liability Partnership (LLP) Other (please detail nature of business) Date of birth (only if natural person) Employer ID number (EIN) Phone Fax 5. TYPE(S) OF SALES WITH WHICH FACILITY WILL BE INVOLVED A. Lodging Services (Check if applicable and check applicable facility below) Yes, Prepared Food and Beverage will be sold along with Lodging Services. No, no Prepared Food and Beverage will be sold along with Lodging Services. CHECK APPLICABLE FACILITY Hotel or Motel Number of guest rooms at facility Bed & Breakfast Number of guest rooms at facility Hostel Number of guest rooms at facility

5 Entire Home, Condo, Townhouse or Apartment (rented for less than 30 consecutive days) Sleeps Bedrooms Bathrooms Please identify property managing agent (if any) who will have interaction with guests: Name Phone Private Room within Home, Condo, Townhouse or Apartment (rented for less than 30 consecutive days) Sleeps Bedrooms Bathrooms Please identify property managing agent (if any) who will have interaction with guests: Name Phone Shared Room within Home, Condo, Townhouse or Apartment (rented for less than 30 consecutive days) Sleeps Bedrooms Bathrooms Please identify property managing agent (if any) who will have interaction with guests: Name Phone

6 B. Prepared Food and Beverage (Check if applicable and check applicable facility below) Restaurant, Cafe or Cafeteria Delicatessen Concession Stand

7 Convenience Store Grocery Store Caterer

8 Bar or Tavern Private Club Food Truck

9 Private Residence 6. Are or will alcoholic beverages be sold at the facility? SELECT ONE Yes No If YES, please check all of the following that apply and for each furnish the Alcohol Beverage Control (ABC) number or numbers under which the facility is operating Beer Wine Mixed Drinks Private Club Beer ABC number Mixed Drinks ABC number Wine ABC number Private Club ABC number 7. If the facility is a seller of Prepared Food and Beverage: Please identify the name, address, and phone number of its three (3) top food suppliers based on amount of purchases or anticipated amount of purchases 8. Is the establishment Identified in section one (1) the result of a purchase or assumption of the operations of an existing establishment? SELECT ONE Yes No If yes, provide the name and A&P Tax Permit number of the former establishment Former Establishment Name Former Establishment A&P Tax Permit Number 9. I DECLARE UNDER PENALTY OF PERJURY THAT THIS APPLICATION (INCLUDING ANY ACCOMPANYING SCHEDULES) HAS BEEN EXAMINED BY ME AND, TO THE BEST OF MY KNOWLEDGE AND BELIEF, IS TRUE, ACCURATE, AND COMPLETE. Electronic Signature of Shareholder/Member/Partner/Officer Title Date